Basic Information
Provider Information | |||||||||
NPI: | 1063948461 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BARAK | ||||||||
FirstName: | VIRGINIA | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1115 SE 164TH AVE DEPT 358 | ||||||||
Address2: |   | ||||||||
City: | VANCOUVER | ||||||||
State: | WA | ||||||||
PostalCode: | 986838004 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3607291253 | ||||||||
FaxNumber: | 3607293185 | ||||||||
Practice Location | |||||||||
Address1: | 3377 RIVERBEND DR | ||||||||
Address2: |   | ||||||||
City: | SPRINGFIELD | ||||||||
State: | OR | ||||||||
PostalCode: | 974778803 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5412226160 | ||||||||
FaxNumber: | 5412226166 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/04/2017 | ||||||||
LastUpdateDate: | 01/26/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 01/26/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | BP10059338 | TX | N |   | Allopathic & Osteopathic Physicians | Pediatrics |   | 208000000X | MD200180 | OR | Y |   | Allopathic & Osteopathic Physicians | Pediatrics |   |
No ID Information.